Form Dc-4329-0412 - Nationwide 457 Enrollment Form - City Of Orlando

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City of Orlando, FL Deferred Compensation Plan
Participation Agreement and Service Request
Participant
Social Security Number
Name
Information
r
Date of Birth
Address
Check
here if this is a
name change
City, State, & Zip Code
Contact Phone Number
(proof of
name change
Alternate/Cell Phone Number
Employer ID Number
must be
0038969001
attached
r
Check
Email Address
Gender
r
r
here if this is a
Male
Female
new address
r
r
r
Type of
New
Reinstatement
Change
Request
Deferrals can start, increase or decrease no earlier than the first day of the month following the month this application is signed.
Start Deferral on: _____________________________________________________________________________________________
Deferral
Deferral Amount: $
%
Payroll Frequency
Summary,
Sub Total: $
%
Payroll
r
r
r
Weekly
Monthly
Semi-Monthly (X)-24
Special: $
%
Frequency
r
r
Total Deferral: $
Bi-Weekly
Other
%
_____________________________
and
Includible Compensation: $
Catch-Up
Catch-Up Provision Utilized
Special Pay Period Ending Dates
Provision
r
r
r
Start:
Yes, 3 year
Yes, Age 50+
No
Stop:
Normal Retirement Age:
Number of Pay Periods:
r
Enroll me in asset rebalancing. I agree to comply with and be bound by the terms and conditions of the service including
any restrictions imposed by the investment options. I understand I can obtain more information about the service, its terms
and conditions by contacting the NRS Service Center.
A
A
(N
®
T
D
S
)
S
C
Funding
SSET
LLOCATION
ATIONWIDE
ARGET
ESTINATIONS
ERIES
MALL
AP
______________% Dreyfus Premier Small Cap Value Fund (Class I)
______________% Nationwide Destination 2015 Fund
Options
______________% Fidelity Advisor Small Cap Fund (Class A)
(Institutional Service Class)
______________% Nationwide
®
Small Cap Index Fund (Class A)
______________% Nationwide Destination 2020 Fund
______________% Oppenheimer Main St. Small Cap Fund (Class A)
(Institutional Service Class)
Only for New
M
C
ID
AP
______________% Nationwide Destination 2025 Fund
______________% Aston/Optimum Mid Cap Fund (Class N)
Business or
(Institutional Service Class)
®
______________% Nationwide
Mid Cap Market Index Fund (Class A)
______________% Nationwide Destination 2030 Fund
Allocation
______________% JP Morgan Mid Cap Growth Fund (Class A)
(Institutional Service Class)
______________% JP Morgan Mid Cap Value Fund (Class A)
______________% Nationwide Destination 2035 Fund
Changes
L
C
ARGE
AP
(Institutional Service Class)
______________% American Century Large Company Value Fund
______________% Nationwide Destination 2040 Fund
(Investor Class)
(Institutional Service Class)
(Must be
______________% American Funds The Growth Fund of America
______________% Nationwide Destination 2045 Fund
(Class R4)
in Whole %
(Institutional Service Class)
______________% Davis New York Venture Fund (Class A)
______________% Nationwide Destination 2050 Fund
______________% Nationwide Large Cap Growth Portfolio
and Total
(Institutional Service Class)
______________% Nationwide
®
S&P 500 Index Fund
______________% Nationwide Retirement Income Fund
(Institutional Service Class)
100%)
______________% Neuberger Berman Equity Funds -
(Institutional Service Class)
Socally Responsive Fund (Investor Class)
______________% T. Rowe Price Growth Stock Fund (Advisor Class)
A
A
(N
®
I
D
S
)
SSET
LLOCATION
ATIONWIDE
NVESTOR
ESTINATIONS
ERIES
______________% INVESCO Van Kampen Growth & Income Fund
______________% Aggressive Fund (Service Class)
(Class A)
B
ONDS
______________% Moderate Aggressive Fund (Service Class)
______________% Moderate Fund (Service Class)
______________% American Funds American High Income Trust
______________% Moderate Conservative Fund (Service Class)
(Class R4)
______________% Conservative Fund (Service Class)
______________% PIMCO Total Return Fund (Class A)
S
PECIALTY
______________% American Century Real Estate Fund (Investor Class)
I
NTERNATIONAL
______________% BlackRock Natural Resources Trust
______________% American Funds Capital World Growth & Income
(Investor A Shares)
F
/C
Fund (Class R4)
IXED
ASH
______________% American Funds EuroPacific Growth Fund (Class R4)
______________% Nationwide
®
Fixed Annuity Contract
______________ _% Nationwide Money Market Fund (Prime Shares)
______________% Total for both columns must equal 100% 1
A
. I
,
,
N
®
I
D
VAILABILITY OF INVESTMENT OPTIONS MAY VARY BY PLAN
F AN ALLOCATION IS MADE TO A CLOSED OR UNAVAILABLE INVESTMENT OPTION
THE ALLOCATION WILL BE MADE TO THE DEFAULT OPTION
THE
ATIONWIDE
NVESTOR
ESTINATIONS
C
F
.
ONSERVATIVE
UND
1. I
100%,
,
N
®
I
D
C
F
. I
F THE TOTAL INVESTMENT OPTION ALLOCATION PERCENTAGE EQUALS LESS THAN
THE DIFFERENCE WILL BE INVESTED IN THE DEFAULT OPTION
THE
ATIONWIDE
NVESTOR
ESTINATIONS
ONSERVATIVE
UND
F THE TOTAL INVESTMENT
100%,
.
OPTION PERCENTAGE IS GREATER THAN
YOUR APPLICATION WILL BE REJECTED AND YOUR ALLOCATIONS WILL NOT BE PROCESSED
Beneficiary
Beneficiary Type
Beneficiary Name
Split %
Relationship
Date of Birth
Designation
r
r
Primary
Contingent
r
r
Primary
Contingent
r
Check here if this is a change of beneficiary. (Beneficiaries listed above replace any prior designation)
PLEASE NOTE: Percentage split must total 100%, and must be in whole percentages.
I authorize my Employer to reduce my salary by the above amount which will be credited to my employer’s Plan. The reduction will continue
Authorization
until otherwise authorized in accordance with the Plan. The withholding of my deferred amount by my Employer and its payment to the
designated investment option(s) will be reflected in the first pay period contingent on the processing of this application by the Plan
Administrator in conjunction with the set-up time required by my payroll center. The reduction is to be allocated to the funding options in the
percentages indicated above. Some mutual funds may impose a short-term trade fee. Please read the underlying prospectuses carefully.
I have read and understand each of the statements on the front and back of this form, which have been drafted in compliance with the
Internal Revenue Code. I accept these terms and understand that these statements do not cover all the details of the Plan or products.
Participant’s Signature
Date
Retirement Specialist’s Signature
Retirement Specialist’s Number
DC-4329-0412
Nationwide Retirement Solutions • P.O. Box 182797 • Columbus, Ohio 43218-2797 • 1-877-NRS-FORU •

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